Client Information and Release Form

Mary Hayes Grieco is the author of Unconditional Forgiveness,The New Kitchen Mystic, and The Peaceful Heart. She is the Director and Lead Trainer of The Midwest Institute for Forgiveness Training in Minneapolis. She has a BA in Psychology from Metro State University. She trained with Dr. Edith Stauffer PhD. From 1986-1990 in her unique method of forgiveness, and has taught and facilitated forgiveness with this method in a variety of venues, and worked in a private practice from 1990 to the present. Mary taught forgiveness retreats at Hazelden Renewal Center from 1992 -2008. Her spiritual self training is eclectic, including yoga philosophy, Twelve Steps, and Chinese Energetic Medicine.

Client Agreement

I understand that Mary Hayes Grieco is a spiritual guide and healer, and a forgiveness coach who uses the model and methods of Unconditional Forgiveness. I understand that Mary’s philosophical framework has evolved out of her own spiritual experiences, and from a synthesis of traditional and non-traditional sources. I understand that she is not a psychologist or psychotherapist. I know that my sessions with Mary are confidential. I understand that at times, forgiveness work can be emotionally intense, and I believe that I can handle my emotions appropriately. I will seek further help and advice from Mary or another mental health professional immediately if I feel overwhelmed by my emotions or in danger of causing harm to myself in any way. I understand that while I am working with Mary, if she perceives that I have challenges that go beyond the scope of her experience she will refer me to appropriate resources, and that she will help me co-ordinate the transfer with my other caregivers.

I consider myself capable of using Mary’s guidance in a mature way, that is, “I will take what’s good for me, and leave the rest.I acknowledge that I am responsible for my own growth, my own decisions, my actions and their consequences.

Payment Agreement

Payment is due on the day of services, in cash, by check, or with a credit card on line at www.maryhayesgrieco.com. Mary does not take insurance. Mary’s fee is $150/hr. in person and $160 by phone, unless another arrangement is made. I will be notified in a reasonable amount of time in advance of changes in services or charges.

Cancellation Policy

There is no cancellation charge for sudden illness or emergencies. Mary requests 48 hour notice for rescheduling your appointment if possible. If you cancel in less than 24 hours of your scheduled time, and your reason for cancelling is neither an illness or emergency, you are responsible to pay for the missed session.

Signed (required)

Your Email (required)

Your Phone # (required)

Your Address (required)

Your Date of Birth

What do you want me to help you with?

How did you here about me?

Are you currently or have you ever been in an ongoing counseling or psychotherapy relationship?

Are you aware of any dysfunctional patterns in the family you have come from(alcoholism, abuse---physical, sexual, or emotional, workaholism, food disorders, physical or emotional neglect, mental illness, sex addiction, other?)

Are you struggling with any addictive behaviors at this time? Specify.

What kind of religious background(if any) do you have? Any ethnic influences?

Do you practice spirituality in any specific manner at this time?

At this point in life, what do you consider to be your greatest strength?